Patient behaviour and dental treatment: ‘Meeting of the minds’
Dentistry is a highly skilled professional service. Its success is based on a multitude of clinical variables that need to be recognized, managed and coordinated in an appropriate way to achieve the end product of treatment. It is increasingly recognized that the provision of dental care should not be viewed in isolation from the psychological makeup and social background of the person receiving the care.
Understanding your patients’ behavioural characteristics and moving beyond the narrowly conceived concept of biology and mechanics that can turn the patient into “just a mouth” will help you treat patients more successfully. The following list describes certain patient behavioural characteristics that may influence dental treatment success.
Inconsistency of dental treatment
It’s not unusual for people to see several dentists during the course of a lifetime. People move from area to area, thus requiring a new local dentist. Patients who see different dentists will exhibit a wide variety of dental history. The majority will demonstrate consistency in care and decision-making. But a certain percentage of individuals will change dentists on a regular basis for a multitude of reasons.
Some patients in mid-treatment will opt to terminate their commitment to completion, not realizing the significant risk they assume. Many of these reasons will lead to compromised care. Some will not see a dentist for long periods of time, others will move from dentist office to dentist office. A study by Steele et al., 1996, listed the following as the main reasons for lack of dental follow-up: lack of perceived need; fear; costs; couldn’t be bothered; and distance.
The lack of continuing care, especially during comprehensive phases of treatment with the diversity of today’s complex dental services, may compromise the patient’s health. We need to inform patients that continuity of their dental care will minimize risks, misdiagnoses and mistreatments.
Fear and anxiety
Nervous patients are the most challenging type of patients to manage. Nervous patients need more time for all procedures, and constant communication is critical. In some instances, mild sedation has proven very helpful. In certain cases, treatment-plan options are designed to shorten the chair time to minimize traumatizing patients.
Coping strategies do exist and have been studied extensively. Stress is “a condition that results when the person/environment transaction leads the individual to perceive a discrepancy between the demands of the situation and the coping resources available” (Lazarus & Folkman, 1984).
Dentists can explain treatments in two ways for fearful patients:
- Procedural, problem-focused approach — information about the procedure (frequently used by dentists).
- Sensory, emotion-focused approach — information about the sensations that may be experienced (less frequently used by dentists).
The sensory approach was more successful in reducing stress, especially in children. How much information is necessary? Thrash et al., 1982, found that more information provided a sense of control for the patients and reduced anxiety for the dental procedure.
The unfortunate reality is that fearful patients visit the dentist less regularly and come only when in severe pain or dysfunction. At this stage, the dentition is usually compromised. The care required is more extensive and serves to perpetuate the negative cycle of fear. Unless you see the patient regularly and use this opportunity to support, encourage and motivate, this cycle will continue until most teeth are deemed unrestorable and extracted. In fact, this anxiety will continue even in the absence of teeth, in the edentulous state.
Parafunction and smoking
The physiology of the mouth is highly influenced by extrinsic and intrinsic factors. Parafunction contributes to tighter oral musculature through clenching and grinding, leading to dental breakdown.
The cause of parafunction is debatable. Some believe it is stress related, others believe it’s an imbalance in neurotransmitters in the central nervous system. Parafunction and stress can reduce salivary flow rates and alter salivary content, thus reducing the protective mechanism available in saliva and increasing rates of decay. The combination of mechanical breakdown and reduced protection can lead to rapid dental destruction. Early diagnoses and treatment is critical to minimize damages.
Smoking also creates an environment that can lead to dental failure. Smoking creates an oral autoimmune disorder by indirectly creating a vasoconstriction of oral blood vessels. This leads to less blood flow and reduced immunity and defense. The lack of blood flow creates tissue ischemia (lack of oxygen), which leads to tissue death. Reduced success rates with periodontal gum surgery and implant surgery have been documented in smokers. If a patient is serious about improved oral health, he or she must quit smoking.
Some patients have realistic expectations and others do not. We have all seen patients who want their teeth very white. And unfortunately, in some cases, white is never white enough.
Some patients feel overly qualified to guide and direct any dental work. But patients are not dentists. They can contribute to — but not control — dental treatment. An overly critical patient may never be satisfied. The key is to have what I consider a “meeting of the minds“ with your patient before treatment is started.
If you don’t understand or agree with the demands and observations of the patient, if you cannot find common grounds to proceed with treatment, if the patient refuses to accept the diagnosis, if the patient has a tendency to dictate treatment: Do not proceed with treatment.
It’s best to refer such patients because you will never be successful treating them.
Compliance with treatment
The success of complicated dental treatment is based on several broad variables: accuracy of the diagnosis, quality of the treatment and the patient’s compliance. Studies have shown multiple determinants influencing compliance:
- Health beliefs: perceived necessity of treatment
- Comprehension: ability to understand the need for treatment
- Temperament: tendency toward compliant or noncompliant behaviour
- Dentist/patient relationship
- Patient satisfaction
- Clinical setting
A five-year study (Holt & McHugh, 1977) of more than 1,000 patients across England showed that 33 percent changed dentists for reasons other than location. Of those who changed their dentist, the most common reason was “unhappiness with previous dentist.” The most important factors for patients when visiting their dentist:
- Dentist care and attention.
- Pain control by dentist.
- Dentist putting patient at ease.
- Waiting time.
- Opening hours.
- Practice décor.
Compliance is critical to successful dental care. Understanding how to manage the determinates of compliance and focusing on the higher priority factors rather than the lower priority ones will lead to greater success.
Dental IQ is the easiest variable to improve. An environment for positive reinforcement is critical to enhance a patient’s education and willingness to fully understand all aspects of treatment.
Outdated dental philosophies are common, and patients need to be informed of the newer, more conservative and successful treatment options.
Distribution of information pamphlets, extended times for patient discussion, and effective use of the Internet have been useful mechanisms to communicate up-to-date dental theories to patients. But not all patients are willing to improve awareness.
The greatest dilemma faced by patients in need of dental treatment is the lack of funds to pay for necessary care. The need for unexpected root canal treatment or prosthetic dentistry, and/or the need for dental implant therapy, can be costly. Patients who have extensive dental problems need to understand that easy fixes don’t exist. Multiple stages of treatment may be required, each one dependant on the next. The successful completion of one stage of treatment helps determine the prognosis of the following stage of treatment.
It is recommended that prior to initiating treatment, you inform the patient of all possible clinical scenarios and costs — along with the likelihood of each occurring. Record and document this discussion clearly in the file or in a patient contract. Patients frequently have difficulty recalling informed discussions about questionable prognoses especially when it comes to risks and costs. Patients must understand the issues and potential consequences. They have a responsibility to themselves and to you. If you don’t have a “meeting of the minds” on these issues, they will resurface at a most unfortunate time.
Do not proceed with treatment until all is clear.
In conclusion: Dentists treat patients. Patients have input. Management of that input allows for success in dentistry. And management starts with a “meeting of the minds.” Sometimes no treatment is the best treatment.
This article was published in Dental Tribune Canada Edition, Vol. 8, No. 4, November 2014 issue.